Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Golden Merced Care Center during CMS and state inspections, most recent first.
Failure to protect a resident from physical abuse when one resident slapped another resident twice in the face after becoming upset that he was in the doorway near the piano room. Staff observed redness to the cheek, blood in the mouth/gum area, tears, pain, and embarrassment. The aggressor had dementia and was ambulatory, while the victim was wheelchair-dependent with a history of brain bleed, weakness, and falls.
Failure to implement fall precautions and 1:1 supervision for a high-fall-risk resident. A resident with dementia, CVA, contractures, functional quadriplegia, epilepsy, and a recent hip fracture fell multiple times after returning from the hospital. IDT notes called for bilateral floor mats and 1:1 companion sitter, but documentation did not confirm these interventions were in place before subsequent falls, and the resident was sent back to the ED more than once after repeated falls.
A resident with hemiparesis from a prior CVA, dependent for ADLs and bed mobility per MDS and Kardex, was receiving a bed bath and linen change when a CNA provided care alone instead of using the required two-person assist. While the CNA turned the resident onto her side to place clean sheets, the resident rolled off the bed onto the floor. The resident was found on her back, unclothed, with blood under her right arm, reporting shoulder pain and having an L-shaped skin tear on the right wrist. Documentation noted the resident’s ongoing anxiety with bed adjustments afterward, and the IDT determined the fall was caused by the CNA not following the Kardex instructions for two-staff assistance and safe bed mobility.
A resident with multiple comorbidities was readmitted from the hospital with documented pressure wounds on the sacrum and right heel. The admitting nurse only identified the right heel wound, failing to assess, document, or communicate the sacral wound as indicated in the hospital discharge summary. As a result, the sacral wound was not evaluated or treated, and wound care staff were not informed, contrary to facility policy requiring comprehensive admission assessments and wound documentation.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report highlights that the environment did not meet required safety standards.
A resident with severe cognitive impairment and a known elopement risk exited the facility undetected, despite wearing a functioning security bracelet. Staff response to the activated door alarm was delayed, and the initial search failed to locate the resident, who was later found in a nearby parking lot and returned without injury. This incident reflects a failure to provide adequate supervision and prevent accidents.
A resident with severe cognitive impairment and a history of stroke was admitted without an elopement risk assessment, contrary to facility policy. This omission led to the resident leaving the facility unsupervised in a wheelchair and being found by an LPN off facility grounds. The required assessment was not completed until over a month after admission.
Fifteen unsecured sliding glass doors in resident rooms allowed a resident with dementia and a history of wandering to elope twice in one day, with the second incident resulting in the resident being found 0.6 miles away in a confused state. The facility lacked alarms or monitoring systems on these doors and exterior gates, and staff confirmed that both residents and unknown visitors could enter or exit without detection.
The facility failed to meet residents' food preferences by removing the microwave and instructing staff not to warm up food, leading to resident frustration. Two cognitively intact residents, with conditions such as heart failure and diabetes, expressed dissatisfaction as they could no longer enjoy their food at acceptable temperatures. The administration cited safety concerns and lack of staff training as reasons for the change, but no alternative solution was provided.
The facility failed to implement baseline care plans within 48 hours for three residents upon admission, as required by policy. Two residents with respiratory conditions and a resident with a PICC line for antibiotic therapy did not have their care needs documented, potentially impacting their care. Interviews with staff confirmed the absence of these plans, which are crucial for guiding care and ensuring residents' health needs are met.
The facility failed to develop comprehensive care plans for four residents, leading to potential health risks. A resident had incomplete care plans for anxiety and antipsychotic medications, while another lacked plans for psychotropic and anti-anxiety medications. Two residents did not have care plans for critical medications and treatments, including anticoagulants, insulin, and hemodialysis. The absence of these plans hindered proper monitoring and care, as acknowledged by the facility's staff.
The facility failed to adhere to physician orders and medication protocols for three residents. A resident with pleural effusion did not receive continuous oxygen as prescribed. Another resident had an incomplete Lidocaine Patch order, leading to potential ineffective pain control. A third resident, at high risk for pressure ulcers, did not have the prescribed Pressure Reduction mattress, and their refusal was not documented. These deficiencies highlight lapses in following facility policies.
The facility failed to properly store medications, with issues including lack of open dates on insulin pens, expired medications, and improper storage of opened bottles. These deficiencies were observed in multiple medication carts and a storage room, posing risks of decreased medication potency and potential medication errors.
The facility failed to store and monitor food according to professional standards, risking foodborne illness. A freezer contained unlabeled frozen chicken, and lacked a thermometer to monitor temperature. During lunch service, the cook did not check the temperature of meat loaf and au gratin potatoes before serving, violating food safety protocols.
The facility failed to maintain a sanitary environment, leading to potential infection risks. A resident's graduated cylinder was found soiled and improperly stored, while another's nasal cannula was on the floor, and nebulizer equipment was stored incorrectly. An expired humidifier solution posed a risk of bacterial growth, and an LPN failed to wear PPE during a dressing change. Additionally, money was improperly stored in a medication cart, risking contamination.
The facility failed to maintain the dignity and privacy of two residents. One resident's urinary catheter bag was left uncovered, visible to others, compromising their privacy. Another resident was subjected to a 20-minute timer for morning ADL care, making them feel rushed and singled out. Both actions violated the facility's policy on dignity and respect.
A resident experienced a major improvement in cognitive function, as indicated by a BIMS score change from 99 to 15, but the facility failed to implement a significant change of condition. The interdisciplinary team did not conduct a formal meeting to address the change, and the plan of care was not updated. The facility's policy requires notification of such changes within 24 hours, which was not followed.
Two residents in a facility experienced deficiencies in IV fluid administration and central line care due to inadequate training and lack of proper procedures. One resident's PICC line was improperly removed, and another's midline dressing change was not performed with sterile technique. Staff interviews revealed insufficient training and reliance on past experiences rather than formal competency validation.
A resident with a history of Paranoid Personality Disorder repeatedly took unauthorized photos and videos of other residents and staff using a smartphone, despite staff awareness and attempts to redirect her. Multiple staff and residents confirmed the ongoing behavior, which included photographing individuals and sensitive information, resulting in violations of resident privacy.
A resident with a high risk of falls did not have a Dycem non-skid mat placed on her wheelchair, despite multiple recommendations from the IDT and documentation in her care plan. The resident, who had conditions such as dementia and muscle weakness, experienced several unwitnessed falls. Observations and staff interviews confirmed the absence of the Dycem mat, highlighting a failure to adhere to the facility's fall risk management policy.
The facility failed to implement fall prevention measures for two residents, including providing non-skid socks and transfer bars as ordered by physicians. Additionally, staff were unable to accurately describe key interventions of the fall prevention program, indicating a lack of understanding of the 4 P's: Pain, Personal belongings, Personal care, and Positioning.
A resident's repeated requests for fried or poached eggs were not honored, despite being cognitively intact and on a regular diet. The facility's policy on pasteurized egg products was initially misinterpreted, leading to the resident being consistently served scrambled eggs instead.
The facility failed to ensure that the designated interdisciplinary team member obtained the hospice plan of care for a resident admitted to hospice services. Despite the resident's significant medical history and hospice admission, the hospice plan of care was not documented in the resident's EMR until after the deficiency was identified.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure one of three sampled residents was protected from physical abuse when Resident 1 slapped Resident 2 twice in the face. Resident 1 was an older female with diagnoses including Alzheimer's disease and dementia and was able to walk independently in the facility. Resident 2 was an older male with diagnoses including bleeding in the brain, muscle weakness, and repeated falls; he was unable to walk and used a wheelchair to move through the facility. Progress notes and staff interviews documented that Resident 1 became upset because Resident 2 was in the doorway near the piano room and wanted privacy with another resident. A CNA observed Resident 1 approach Resident 2, grab his wheelchair, and slap him twice on the face with an open hand. Staff documented redness to the left cheek, blood in the mouth/gum area, pain, tears, and mental anguish, with Resident 2 crying and stating he was embarrassed. The facility policy defined abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and physical abuse included slapping.
Failure to Implement Fall Precautions and 1:1 Supervision
Penalty
Summary
The facility failed to implement adequate supervision, care planned interventions, and IDT-recommended safety measures for a resident who was at high risk for falls. The resident had a history of dementia, CVA, gout, sacral pressure ulcer, bilateral upper and lower contractures, functional quadriplegia, left femur fracture, and epilepsy. He fell out of bed at the facility on 4/19/26, struck his head, had a loss of consciousness, and was sent to the ER, where imaging identified a right femoral fracture and avulsion fracture of the right greater trochanter. The resident was admitted to the hospital for a closed right hip fracture. After the first fall, the IDT fall review dated 4/20/26 documented recommendations to offer fall mats bilaterally to decrease potential injury. The resident returned to the facility on 4/23/26 and was described as restless on readmission. Nursing documentation showed that he was found on the floor at 6:35 p.m. on his left side next to the bed, was assisted back to bed, and placed on neuro checks. At 8:20 p.m. the same evening, he was again found on the floor next to his bed on his left side. He was then placed on 1:1 for safety. The NC stated she could not find updated documented interventions after the first fall on 4/23/26 that could have prevented the second fall, and could not find documentation that fall mats were placed as recommended after the 4/19/26 fall. The resident was sent to the ED on 4/24/26 after the two falls and returned to the facility later that day. The IDT fall review dated 4/24/26 documented bilateral floor mats, a 1:1 companion sitter, wide mattress, and 72-hour alert charting. The resident fell again on 4/25/26 and was found on the floor on a safety mat in a fetal position with his knees drawn toward his chest. Nursing documentation stated that a new order for 1:1 with the patient for safety was placed after this fall, along with neuro checks and stat right hip x-rays. The NC, ADON, ADM, and nursing staff stated they could not find documentation confirming that the 1:1 sitter was in place before the second fall on 4/23/26 or at the time of the fall on 4/25/26, and they stated the documentation did not reflect that the sitter was restarted when the resident returned from the ED.
Failure to Follow Two-Person Assist Requirement During Bed Bath Leading to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision during a bed bath and linen change for one of four residents. A CNA (CNA 2) provided a bed bath and changed linens for Resident 3 without obtaining the required assistance of a second staff member, despite the resident’s Kardex specifying that two staff were needed for bed mobility and turning/repositioning in bed. CNA 2 reported that she turned the resident onto her side to place a clean sheet, and the resident then rolled all the way over onto the floor. CNA 2 acknowledged that she was working alone and that she did not check the Kardex as often as she should, and the IDT later determined the fall was caused by CNA 2 not following the Kardex appropriately. Resident 3 was an older adult with significant functional impairments, including inability to move her right arm and leg due to a prior stroke, and documented dependence on staff for ADLs and bed mobility. The MDS indicated that she was dependent for self-care, had upper and lower extremity impairments, and required that a helper complete all effort for rolling left and right, with assistance of two or more helpers needed for that activity. The Kardex specifically directed that two staff assist with turning and repositioning in bed and to ensure a safe environment. Despite these documented needs and instructions, CNA 2 proceeded to perform the bed bath and linen change alone. Following the incident, staff documentation indicated that the charge nurse was called to the room around 10 a.m. and found the resident on her back on the floor, unclothed, with blood under her right arm and an L-shaped skin tear on the top of her right wrist measuring 3–4 cm. The resident reported shoulder pain and appeared anxious when the head of the bed was elevated during subsequent brief changes and medication administration, requiring reassurance and confirmation that the bed was in the lowest position. Progress notes also documented ongoing anxiety when the bed was adjusted, with staff again reassuring the resident and ensuring the bed was in the lowest position before leaving the room. The facility’s documentation and interviews consistently linked the fall to the CNA’s failure to follow the Kardex requirement for two-person assistance during bed mobility.
Failure to Identify and Document All Wounds on Readmission
Penalty
Summary
The facility failed to accurately identify and document all wounds present on a resident's readmission from the hospital. Upon review of the resident's hospital discharge summary and history and physical, it was indicated that the resident had two pressure wounds: one on the sacrum and one on the right heel. However, during the facility's admission process, only the right heel wound was identified and documented by the admitting nurse. The sacral wound, which was noted in the hospital records as infected, was not assessed, documented, or communicated to the wound care provider upon the resident's return. Interviews with facility staff, including the DON, LVNs, and the wound care NP, confirmed that the admitting nurse did not complete a thorough head-to-toe skin assessment or review the hospital discharge summary in detail. As a result, the sacral wound was not recognized, and no treatment orders were initiated for it. The wound care nurse and NP were not made aware of the sacral wound, and the resident was not included in wound care rounds or assessments for that area. The facility's policies required a comprehensive admission evaluation, including documentation and measurement of all wounds, and obtaining treatment orders, but these procedures were not followed in this instance. The resident involved had multiple complex medical diagnoses, including type 2 diabetes, anemia, chronic atrial fibrillation, chronic kidney disease, heart failure, and pancytopenia, all of which increased the risk for skin breakdown and infection. Despite being at high risk and returning from the hospital with documented wounds, the facility's failure to identify and address all wounds led to a lack of assessment and treatment for the sacral wound following readmission.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions by staff or details about the residents involved are not provided in the report.
Resident Elopement Due to Delayed Staff Response to Security Alarm
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a known history of elopement risk exited the facility without staff knowledge. The resident was last seen ambulating in a hallway and was later found approximately 350 feet away in a nearby fast-food restaurant parking lot. The facility had an electronic security bracelet system in place for the resident, which was functioning at the time, and a door alarm was activated. However, staff response to the alarm was delayed, with the responding LVN arriving at the door within five minutes, searching the area, but failing to locate the resident. The resident was ultimately found and returned to the facility by staff after being identified by a former employee outside the premises. The resident's records indicated a history of impaired cognition and previous elopement risk, with interventions in place such as a security bracelet. Despite these measures, the staff did not respond to the door alarm within the facility's expected timeframe of one minute or less, and the initial search did not result in locating the resident. The facility's policy defined elopement as a resident exiting without staff knowledge, which occurred in this incident. No injuries were noted upon the resident's return, but the event demonstrated a failure to provide adequate supervision and prevent accidents as required.
Failure to Assess Elopement Risk at Admission Resulting in Resident Elopement
Penalty
Summary
The facility failed to assess a resident for elopement risk factors upon admission, as required by facility policy. The resident, who had a history of cerebral infarction, impaired cognition, and alcohol abuse, was admitted without a completed Nursing Admission Evaluation to determine elopement risk. The Minimum Data Sheet indicated the resident had severely impaired cognition, and the facility's policy required that an elopement risk assessment be completed at admission. However, the assessment was not performed until 41 days after admission. As a result of this omission, the resident was able to leave the facility unsupervised in a wheelchair and was found by a staff member approximately 1,000 feet from the facility. The staff member returned the resident to the facility, and a Wander Guard was applied afterward. Interviews with staff confirmed that the elopement risk assessment was not completed as required, and the administrator acknowledged the failure to follow policy regarding timely assessment at admission.
Unsecured Sliding Glass Doors Lead to Resident Elopement
Penalty
Summary
The facility failed to ensure the safety and security of its residents by not securing 15 sliding glass doors located in resident rooms, which provided direct access to the exterior of the building. These doors were not equipped with alarms or any system to alert staff when opened, and the gates leading from the exterior walkways to the parking lot and city streets were also unsecured. Maintenance staff confirmed that there was no system in place to monitor these exits, and the administrator acknowledged that ambulatory residents could leave or unknown visitors could enter the facility without staff knowledge through these doors. A resident with diagnoses including dementia, psychosis, and disorientation, and who was identified as an elopement risk, was able to leave the facility twice in one day through one of these unsecured sliding glass doors. On the second occasion, the resident was found by staff 0.6 miles from the facility in a confused state after having crossed multiple lanes of traffic. Progress notes and interviews with staff confirmed that the resident left through her room's sliding glass door, which did not have an alarm, and that the exterior gates were also not locked. The facility's own policy required evaluation and implementation of appropriate interventions for residents at risk of wandering or elopement, but records and interviews indicated that these measures were not in place for the 15 sliding glass doors. The facility assessment documented that the facility serves residents with impaired cognition, memory loss, and dementia, further underscoring the vulnerability of the population affected by the lack of secure exits.
Facility Fails to Accommodate Residents' Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of residents by not providing a means to warm up food brought in from outside. This issue arose when the facility removed the microwave from the resident food storage area and instructed staff not to warm up food for residents. This decision led to frustration among residents who were unable to enjoy their food at acceptable temperatures for palatability. Two residents, both cognitively intact, expressed their dissatisfaction with the new policy. One resident, who had been admitted with heart failure, diabetes mellitus type II, and kidney failure, stated that he relied on food brought in for evening snacks and was frustrated by the inability to have it warmed. Another resident, admitted with heart failure, supraventricular tachycardia, and morbid obesity, also expressed that the facility was violating her rights by not heating up the food her family brought her. The facility's administration cited safety concerns and lack of staff training as reasons for the removal of the microwave. The Director of Staff Development mentioned that CNAs were not equipped with thermometers or trained to properly heat food, and the Administrator noted the absence of a temperature log. Despite several residents' complaints, the facility had not provided an alternative solution to heat up food for residents.
Failure to Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans for three residents within 48 hours of their admission, as required by their policy. Residents 221 and 222, who were admitted with respiratory conditions such as pleural effusion, pneumonia, and COPD, did not have their baseline care plans completed. This omission meant that their respiratory care needs, including the use of oxygen, were not properly documented or planned for, potentially impacting their care. Interviews with the LVN and MDSRN revealed that the responsibility for creating these care plans lay with the nurses, and the absence of these plans could hinder the staff's ability to provide appropriate care. Resident 421, admitted with a PICC line for antibiotic therapy, also did not have a baseline care plan implemented within the required timeframe. The absence of a care plan for the PICC line meant that specific care instructions and monitoring strategies were not documented, which could have led to a decline in the resident's health. Interviews with the DON and RN confirmed that a care plan should have been in place to guide the care and ensure the resident's health needs were met. The facility's policy on baseline care plans, dated March 2022, mandates that a plan be developed within 48 hours of admission to address immediate health and safety needs. This policy was not adhered to for the three residents, as evidenced by the lack of documented care plans for their specific medical conditions and treatments. The failure to implement these plans could have compromised the quality of care provided to the residents, as it left staff without clear guidance on how to meet their immediate health needs.
Incomplete Care Plans for Residents' Medications and Treatments
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to potential risks for their health and well-being. Resident 71 had an incomplete care plan for anxiety medication and lacked care plans for Sertraline and Olanzapine, which are crucial for managing their mental health conditions, including bipolar disorder and PTSD. The absence of specific goals and monitoring parameters in the care plan for anxiety medication was acknowledged by LVN 3, who emphasized the importance of having a specific number of episodes to observe to evaluate the medication's effectiveness. Resident 72 did not have individualized care plans for Quetiapine, Buspirone, and Lorazepam, despite these medications being prescribed to manage their bipolar disorder and anxiety. The care plans for these medications were created after the medications were ordered, which LVN 3 noted should have been done concurrently to ensure proper monitoring and effectiveness. The Director of Nursing (DON) confirmed the oversight and stressed the importance of comprehensive care plans for short-term residents to facilitate their recovery and return to baseline prior to discharge. Resident 223 lacked care plans for Apaxiban, insulin, diabetic care, and hemodialysis, which are essential for managing their complex medical conditions, including Type II Diabetes and End Stage Renal Disease. The absence of these care plans posed a risk of inadequate monitoring and care. Similarly, Resident 47 did not have a care plan for apixaban, an anticoagulant, which is critical for preventing blood clots and managing their heart condition. The DON and MDS Nurse acknowledged the importance of timely and complete documentation to ensure resident-centered care.
Non-Compliance with Physician Orders and Medication Protocols
Penalty
Summary
The facility failed to meet professional standards of quality for three residents due to non-compliance with physician orders and medication administration protocols. Resident 221, who was admitted with a primary diagnosis of pleural effusion, did not receive the prescribed continuous oxygen therapy. During an observation, it was noted that the resident's oxygen concentrator was turned off, and the nasal cannula was stored in a bag. The Licensed Vocational Nurse (LVN) confirmed that the resident required continuous oxygen delivery, and the Director of Nursing (DON) acknowledged that the resident might have received an inappropriate amount of oxygen due to the lack of adherence to the physician's order. Resident 321 experienced a deficiency in medication administration. The resident had an order for a Lidocaine Patch to be applied for pain relief, but the order did not specify the exact location for application. During an observation, the LVN placed the patch on the resident's right shoulder, although the resident expressed pain in a different area. The Pharmacy Consultant and the DON both confirmed that the medication order was incomplete, lacking specific instructions on where to apply the patch, which could lead to ineffective pain control. Resident 4, who was at high risk for pressure ulcers due to paraplegia and other conditions, did not have the prescribed Pressure Reduction mattress in use. The resident was observed lying on a regular mattress, and the LVN stated that the resident had refused the specialized mattress, although this refusal was not documented. The DON confirmed that the physician should have been informed of the refusal, and the lack of documentation and communication could result in the resident's wounds worsening. The facility's policies on medication orders and pressure injury prevention were not followed, contributing to these deficiencies.
Medication Storage Deficiencies in Facility
Penalty
Summary
The facility failed to properly store medications in several areas, including three medication carts and one medication storage room. In the South one medication cart, an unopened insulin pen intended for refrigeration was found not stored as recommended, and multiple medications for several residents lacked open dates. This oversight could lead to the use of medications past their effective date, potentially compromising their therapeutic effectiveness. In the South two medication cart, six insulin pens for various residents were found without open dates, and expired medications were present. Additionally, several eye drop bottles and respiratory medications lacked open dates. The presence of expired and improperly labeled medications increases the risk of medication errors, as noted by the staff during interviews. The North one medication cart contained discontinued medication and multi-dose medications without open dates. An expired over-the-counter medication was also found. In the North medication storage room, expired medications, incorrectly labeled expiration dates, and opened bottles stored inappropriately were observed. These deficiencies highlight the potential for decreased medication potency and the risk of administering expired or discontinued medications, as emphasized by the staff and pharmacy consultant during interviews.
Food Safety Deficiencies in Storage and Temperature Monitoring
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. In one of the freezers, a clear plastic bag containing what appeared to be frozen chicken was found without any labels or closure device. The District Manager of the kitchen acknowledged that the meat should have been stored in a labeled, airtight container to ensure food freshness and safety. The absence of proper labeling and storage could lead to serving expired foods, increasing the risk of foodborne illness among residents. Additionally, the facility did not have a thermometer in the chest freezer to monitor the internal temperature, which is crucial for preventing bacterial growth. The Dietary Aid confirmed that a thermometer should be present and checked daily. Furthermore, during a lunch tray line service, the cook failed to take the temperature of the meat loaf and au gratin potatoes before serving, which is a necessary step to ensure food safety. The facility's policy and procedure, as well as the California Code of Regulations, emphasize the importance of maintaining specific temperatures for food storage and service to prevent contamination and ensure the safety of the food served to residents.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment, leading to potential cross-contamination and infection risks for several residents. Resident 25's graduated cylinder, used for measuring urine output, was found visibly soiled, uncovered, and unlabeled on top of a shared toilet. This oversight was acknowledged by the LVN, Infection Preventionist (IP), Assistant Director of Nursing (ADON), and Director of Nursing (DON), all of whom recognized the potential for cross-contamination and infection due to improper storage and lack of cleaning. Resident 20's nasal cannula was observed touching the ground, and nebulizer equipment was improperly stored in the same bag as the nasal cannula. The IP, Central Supply Clerk (CSC), ADON, and DON all noted that this improper storage and handling could lead to cross-contamination and infection, as the nasal cannula delivers oxygen directly to the resident's mucosal membrane. The CSC admitted responsibility for replacing and properly storing the equipment, which was not done in this case. Resident 12's humidifier bottle and solution were found expired and not replaced, posing a risk of bacterial growth and respiratory infection. The IP, CSC, ADON, and DON all acknowledged the oversight, with the CSC admitting failure to change the humidifier bottle and solution as required. Additionally, LVN 5 failed to wear appropriate PPE while performing a dressing change for Resident 371, increasing the risk of infection. Lastly, money was improperly stored in the South one medication cart, which could lead to contamination of medications. The IP, Pharmacy Consultant (PC), and DON were unaware of this practice and recognized it as an infection control issue.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and privacy of Resident 25 by not covering their urinary catheter bag with a dignity bag. This oversight was observed during a room visit, where the catheter bag was visible to other residents and visitors, potentially compromising the resident's dignity and privacy. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) both acknowledged that the catheter bag should have been covered, as per the facility's policy and procedure on dignity, which emphasizes the protection of resident privacy and confidentiality. Resident 47 experienced a violation of their right to dignity when the facility implemented a 20-minute time limit for morning Activities of Daily Living (ADL) care using a timer. This practice made the resident feel rushed and singled out, as no other resident was subjected to such a time constraint. The resident's family member expressed frustration over this practice, and the Certified Nursing Assistant (CNA) confirmed the use of the timer to limit the time spent on morning care. The DON admitted that using a timer was an extreme first step and acknowledged that it could make the resident feel singled out. Both deficiencies highlight the facility's failure to adhere to its policy on treating residents with dignity and respect. The policy explicitly prohibits demeaning practices and emphasizes the importance of maintaining resident privacy and allowing residents to exercise their rights without discrimination or reprisal. The facility's actions in both cases were inconsistent with these standards, leading to the reported deficiencies.
Failure to Implement Significant Change of Condition for Resident
Penalty
Summary
The facility failed to implement a significant change of condition for a resident who experienced a major improvement in mentation. The resident, who was initially unable to make her needs known and was not her own responsible party, showed a significant improvement in cognitive function as indicated by a BIMS score change from 99 to 15. Despite this improvement, no significant change of condition was completed, and the plan of care was not updated to reflect the change in mentation. The deficiency was identified through interviews and record reviews, which revealed that the facility's interdisciplinary team did not conduct a formal meeting to address the resident's change in condition. The MDS Coordinator and the Social Services Director acknowledged the oversight, noting that the change in BIMS score should have triggered a change of condition. The facility's policy requires notification of a significant change in a resident's condition within 24 hours, but this was not adhered to in this case.
Deficient IV Fluid Administration and Central Line Care
Penalty
Summary
The facility failed to administer parenteral fluids in accordance with professional standards of practice for two residents, leading to potential adverse outcomes. Resident 421 was admitted with a PICC line for IV antibiotics, but the facility lacked an approved policy and procedure for PICC line care. Registered Nurses and the Assistant Director of Nursing were not trained in PICC line care, resulting in improper removal of the PICC line by RN 1, who used a band-aid instead of an occlusive dressing and did not instruct the resident to lay flat post-removal. Resident 422 was admitted with a midline for IV antibiotics, but the facility also lacked an approved policy and procedure for midline care. During a dressing change, the Assistant Director of Nursing failed to follow sterile technique, allowing the midline to touch non-sterile linens and not ensuring the resident wore a mask. The midline was not in proper placement and had to be removed, indicating a lack of proper training and competency in central line management. Interviews with facility staff revealed that nurses were insufficiently trained in central line care and management, relying on past job experiences rather than formal training. The Director of Nursing acknowledged the need for competency in central line management and the potential harm from inadequate training, including complications such as infections or air embolisms. The facility's policies and procedures were not adequately followed, and there was a lack of documented training and competency validation for staff handling central lines.
Failure to Protect Resident Privacy Due to Unauthorized Photography
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records when a resident with a diagnosis of Paranoid Personality Disorder repeatedly took photographs and videos of other residents and staff without their consent. Multiple staff members, including the Social Services Director, Assistant Director of Nursing, and a Registered Nurse, observed the resident using her smartphone to take photos of residents, staff, hallways, nurses' stations, and even patient names and room numbers. Progress notes documented the resident's ongoing behavior, including verbal aggression and refusal to comply with redirection efforts. Other residents and staff confirmed that the resident frequently took photos and videos, sometimes following residents to their doorways to do so. One cognitively intact resident reported being followed and photographed against their wishes, and a Certified Nursing Assistant stated that the resident showed her the photos and videos taken of other residents. Despite staff attempts to redirect the resident and discussions with her about not taking pictures, the behavior persisted, resulting in the violation of an unknown number of residents' privacy rights.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident, identified as Resident 3, who was at risk for falls. Despite multiple recommendations from the Interdisciplinary Team (IDT) meetings following several unwitnessed falls, the facility did not place a Dycem non-skid mat on the resident's wheelchair. The resident's care plan, which was undated, indicated the need for a Dycem mat on the wheelchair as an intervention to mitigate fall risks. However, during observations and interviews conducted on November 22, 2024, it was noted that the Dycem mat was not present on the resident's wheelchair, contrary to the care plan and IDT recommendations. Resident 3 had a history of conditions that increased her fall risk, including anemia, muscle weakness, difficulty walking, abnormalities in gait and mobility, and dementia. The Minimum Data Sheet (MDS) assessment indicated that the resident had moderately impaired cognition and required substantial assistance for transfers. Despite these documented needs and the facility's policy on managing fall risks, the necessary intervention of placing a Dycem mat was not executed, as confirmed by staff interviews and record reviews.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement necessary physical interventions to mitigate fall risks for two residents as part of their fall prevention program. Resident 1, who was diagnosed with conditions such as dorsalgia, unspecified dementia, and osteoporosis, was identified as high fall risk. Despite a physician's order for non-skid socks as a fall prevention measure, Resident 1 was observed without them on multiple occasions. The resident had a history of falls, with nine incidents since admission, and was noted to be severely cognitively impaired. The facility's care plan and physician's orders clearly indicated the need for non-skid socks, yet these were not provided, as confirmed by a Certified Nursing Assistant who was unable to locate them. Resident 2, diagnosed with epilepsy, muscle weakness, and osteoporosis, was also at risk for falls. The resident's care plan and physician's orders specified the use of two transfer bars for assistance with bed mobility and transfers. However, during an observation, only one transfer bar was found on the resident's bed. This discrepancy was confirmed by a Licensed Vocational Nurse, who acknowledged that the resident's physician's orders were not being followed. The resident had previously expressed concerns about the lack of side rails, indicating a heightened awareness of her fall risk. Additionally, the facility staff demonstrated a lack of understanding of the fall prevention program's key interventions, specifically the 4 P's: Pain, Personal belongings, Personal care, and Positioning. Interviews with three staff members revealed that none could accurately describe all four components, which are crucial for effective fall prevention. The Director of Nursing acknowledged the expectation that staff should be aware of these interventions, yet the deficiency in staff knowledge persisted, potentially compromising resident safety.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, specifically the request for fried or poached eggs. The resident, who was cognitively intact and on a regular, fortified diet with thin liquids, repeatedly asked for fried or poached eggs but was consistently served scrambled eggs instead. The resident had communicated this preference to dietary staff and mentioned it during a resident council meeting, but the request was not accommodated. The facility's policy required the use of pasteurized egg products for soft-cooked egg items, which the Dietary Manager initially interpreted as a restriction against serving fried or poached eggs. Upon review, the Dietary Manager acknowledged that the facility could accommodate the resident's preference for fried eggs by using shelled eggs. The Director of Nursing and the Administrator both stated that they expected staff to notify dietary and nursing staff of specific food requests to ensure residents' preferences were honored. Despite these expectations, the resident's request for fried or poached eggs was not fulfilled, leading to the deficiency noted in the report.
Failure to Obtain Hospice Plan of Care
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the hospice plan of care for Resident #27, who was admitted to hospice services. The facility's policy required the Director of Nursing (DON) to coordinate care and obtain the hospice plan of care, but the DON was unaware of this responsibility until informed by the Administrator. Interviews with various staff members, including Licensed Vocational Nurse (LVN) #1, Registered Nurse (RN) #2, RN #3, and the Medical Records Director (MRD), revealed that the hospice plan of care for Resident #27 was not documented in the resident's electronic medical record (EMR) until 05/01/2024, despite the resident being admitted to hospice on 04/03/2024. Resident #27 had a significant medical history, including stage four pressure ulcers, dementia, type two diabetes mellitus, and a history of malignant neoplasms. The resident's comprehensive care plan indicated hospice admission on 04/03/2024, but the hospice plan of care was not available in the EMR. The MRD received a packet of hospice records on 05/01/2024, but there was no prior documentation of the hospice plan of care. The DON and other staff members confirmed that the hospice plan of care should have been provided and maintained in the resident's EMR, but this was not done until after the deficiency was identified.
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What surveyors actually found near you
We read the 82 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Merced
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Merced Nursing & Rehabilitation Ctr | 0.2 mi | ★★★★★ | 1 | 0 |
| La Sierra Care Center | 0.3 mi | ★★★★★ | 16 | 0 |
| Franciscan Post-acute Care Center | 0.5 mi | ★★★★★ | 3 | 0 |
| Merced Behavioral Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Anberry Post Acute | 3.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.